5007 PLAN OF CARE

5007.1 Each Provider shall conduct an initial assessment of the beneficiary's functional status and needs within forty-eight (48) hours of receiving the referral for services.

5007.2 Each Provider shall document in writing, a written plan of care within seventy-two (72) hours of the initial assessment of the beneficiary based upon the beneficiary's functional limitations.

5007.3 The plan of care shall specify the frequency, duration and expected outcome of the services rendered.

5007.4 The plan of care shall only be approved and signed by the beneficiary's primary care physician or advanced practice registered nurse who has a prior relationship with the beneficiary and has examined the beneficiary in a hospital, nursing facility, or primary care physician's office or at the beneficiary's home; and shall be re-certified no less than every six (6) months after the initial certification and each re-certification thereafter.

5007.5 The plan of care shall be re-certified by the primary care physician or advanced practice registered nurse after any interruption of service, greater than fourteen (14) calendar days, including hospital admissions.

5007.6 A registered nurse who is employed by the Provider shall review the plan of care at least once every sixty two (62) days and shall update or modify the plan of care as needed. The revised plan of care shall be signed by the referring primary care physician or advanced practice registered nurse within thirty (30) days of prescription

5007.7 If a plan of care is revised by telephone order, the telephone order shall be immediately documented in writing and signed by the primary care physician or advanced practice registered nurse within thirty (30) days of its prescription.

SOURCE: Final Rulemaking published at 50 DCR 3957 (May 23, 2003); as amended by Notice of Final Rulemaking published at 59 DCR 1760, 1772 (March 2, 2012).